Steele, K., & Van der Hart, O. (2013).

Understanding attachment, trauma and

dissociation in complex developmental trauma disorders In A. Danquah & K. Berry
(Eds.) Attachment theory in adult mental health: A guide to clinical practice (pp.
78-94). Abingdon, UK: Routledge.

Chapter 6

Understanding attachment,
trauma and dissociation in
complex developmental
trauma disorders
Kathy Steele and Onno van der Hart

Introduction
The heart of psychotherapy is in understanding and changing the ways in which
individuals experience, develop and maintain human relationships. Attachment
theory and the field of interpersonal neurobiology have gifted us with a nuanced
and powerful understanding of relationships, the mental representations of self
and other that shape relationships, and the regulatory and organising functions of
attachment. No one is more in need of help with attachment and regulation than
those who have been chronically abused and neglected in childhood. These
individuals generally suffer from a wide array of symptoms that can be understood
as complex developmental trauma disorders, including Complex Posttraumatic
Stress Disorder (C-PTSD), trauma-related Borderline Personality Disorder (BPD)
and the Dissociative Disorders. Our emphasis in this chapter will be on working
with attachment problems in patients who have a dissociative disorder.
Individuals who experienced chronic childhood interpersonal traumatisation have
had their development adversely impacted early in life across broad areas of
functioning. This leaves them with an unstable foundation for future healthy
development and adaptation, putting them at risk for ongoing psychological,
physiological and relational problems. These developmental issues distinguish them
from those who have classic PTSD related to a single traumatising incident that has
not altered the individuals early developmental trajectory (Courtois and Ford 2009).
Although in recent years mental health professionals have developed a much
greater understanding of the relationship between childhood abuse and neglect and
attachment difficulties across the lifespan, many clinicians have yet to grasp the
central role of dissociation in generating and maintaining serious symptoms,
including many major attachment difficulties. In fact, dissociation is not only an
intrapsychic phenomenon but also an interpersonal one, being highly reactive to what
is happening in relationships in the present (Liotti 2009). Thus we will place a special
emphasis in this chapter on working with dissociation in the context of attachment.
The chapter begins with a description of how early secure attachment supports
regulation and integration of the child, and how abuse, neglect and severe
attachment disruptions adversely affect development. These overwhelming

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experiences create fertile ground for the child to dissociate, as she or he has the
impossible task of trying to live normal daily life while under chronic threat.
Dissociation in trauma is described, so that clinicians have a solid foundation and
rationale for integrative treatment interventions. Specific trauma-related phobias
that maintain dissociation and their treatment are discussed.
Treatment of dissociation and related attachment problems will be delineated
within a phase-oriented treatment approach that is the current standard of care
(Boon, Steele and Van der Hart 2011; Chu 2011; Cloitre, Cohen and Koenen
2006; Courtois and Ford 2009; Davies and Frawley 1994; Howell 2011; ISSTD
2011; Van der Hart, Nijenhuis and Steele 2006). Phase-oriented treatment is based
on the premise that early trauma and attachment disruptions limit integrative
capacity and impede self and relational regulation skills. Therefore, treatment
begins with an initial phase of stabilisation, ego strengthening, and skills building.
The second phase focuses on treatment of traumatic memory and the final phase
on a more adaptive integration of the individuals functioning across all domains.
Within each phase, treatment of trauma-related phobias that maintain dissociation
will be addressed. Due to space limitations, treating the phobia of attachment and
of attachment loss in the first phase of treatment will be emphasised in this chapter.

Attachment, trauma and dissociation

Children need safe, consistent and predictable relationships for healthy
development of self-regulation, maturation and integration (Porges 2011; Schore
2003). These types of relationships can only occur when we feel safe. It is difficult
to maintain a sense of relationship when in danger, particularly when it involves
severe, or life, threat. Fortunately, evolution has endowed us with the capacity to
distinguish between safety and threat so that we can have secure relationships that
support our development and integration.
The integrative functions of safe attachment
When we feel safe, an inborn neural organisation or action system called the
social engagement system helps us to regulate ourselves and connect well with
others (Porges 2011). The social engagement system is the physiological
foundation for secure attachment. Via the vagal nerve branches, our physiology is
organised to support social behaviour such as movement, hearing and speaking
that facilitates bonding and attachment. Specifically, the vagal nerve supplies the
muscles that control the social cues of eye gaze, facial expression, head movements
and prosody (the rhythm, stress and intonation of our voices). The vagal nerve
also helps control heart rate and thus our arousal level. The social engagement
system helps us maintain a calm state of being that promotes growth, integration
and restoration (Porges 2011).
Secure attachment supports the hard wiring of the childs brain that will
determine to a large degree how well he or she is able to regulate and relate to

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others across the lifespan (Schore 2003). Consistent activation of the social
engagement system via secure attachments helps maintain a regulated
psychobiological foundation that supports ongoing integration of the childs
personality, that is, the consistent and predictable ways of being that define the
child. The child learns not only to depend safely upon others to help soothe and
reassure but also to self-regulate and to integrate experience and a consistent sense
of self across time and situations.
Activation of action systems of daily life
Secure attachment and the social engagement system support activation of other
inborn action systems necessary for adaptive functioning in life (Van der Hart,
Nijenhuis and Steele 2006). These include exploration (so that we can be curious
and learn about our environment), play (supports learning and relating to others),
caregiving, socialness (so we can relate within groups), energy management
(healthy eating, sleeping and rest patterns) and sexuality (so that we can reproduce
and maintain our species) (Lichtenberg and Kindler 1994; Panksepp 1998; Van
der Hart, Nijenhuis and Steele 2006).
Inhibition of defence
Secure attachment not only activates functions that support adaptive living, it also
inhibits unnecessary defence. For example, a child might be frightened by dogs,
but the parent reassures and supports the child in slowly approaching and petting
a friendly dog and gradually teaches the child to read the cues of whether it is safe
to approach a particular dog. Secure attachment has deactivated the defensive
reaction in the child and supports the childs return to a regulated state where
ongoing integration can continue.
Defence against threat
Serious threat automatically activates defence and overrides the action systems of
daily life, including the social engagement system. A chronically fearful and
insecure person experiences persistent problems in many of the functions that are
organised by these action systems, which we can easily see in chronically
traumatised individuals. For example, in addition to relational problems, they
often have trouble being curious and trying new things (exploration), may have
anxiety in groups (socialness), have sleep and eating difficulties (energy
management), sexual problems (sexuality), tend to over or under care-take others
(caretaking), and are unable to enjoy themselves through play (Van der Hart,
Nijenhuis and Steele 2006).
From an evolutionary standpoint, secure attachment itself is an important firstline defence against threat, as living within a protective group or being in the care
of a stronger, more able person is much safer than being out on ones own (Porges

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2011). For example, when a young child feels discomfort or distress, or is mildly
threatened, the first thing he or she will do is call out for a caregiver. This is a
natural defence called the attachment cry, and involves panic, frantic searching
and crying, and clinging behaviours (Ogden, Minton and Pain 2006; Steele, Van
der Hart and Nijenhuis 2001; Van der Hart, Nijenhuis and Steele 2006; Van der
Kolk 1987). Its purpose is to engage the caregiver for support, help and reassurance,
so that the child can return to a calm, comfortable state.
However, when threat becomes too great, the child no longer searches for an
attachment figure but instead automatically reacts with evolutionary prepared
defences: freeze, flight, or fight, each mediated by the sympathetic nervous system,
resulting in extreme hyperarousal. When threat is severe enough to be perceived as
life threatening, the child may collapse in a kind of death feint, mediated by the
(dorsal vagal) parasympathetic system, resulting in extreme shut down and
hypoarousal (Porges 2011; Van der Hart, Nijenhuis and Steele 2006). For infants
and young children, even non-violent severe attachment disruptions such as
neglect or abandonment can be physiologically interpreted as a life-threatening
catastrophe, evoking chronic defence (Bowlby 1969/82; Liotti 2009; Schore
2003). These defence reactions are readily observed in chronically traumatised
patients, and recognising and treating them is an essential part of treatment.

Dissociation
When the childs caregiver is seriously abusive or neglectful, the natural capacities
to distinguish between safety and threat, to become securely attached and engage
in all the functions of daily life, to defend oneself when in danger and to integrate
experience over time become greatly complicated and confused. The abused child
is dysregulated on a chronic basis without sufficient relational support to return to
a normal baseline that supports integration. Most importantly, the child is faced
with the impossible task of simultaneously approaching the caregiver out of need
and an inborn need to attach, and avoiding or defending against the same person.
Under these conditions of chronic threat, the child dissociates, unable to make
sense of and integrate the highly discrepant needs to attach and defend at the same
time. As Liotti (2009) noted, this approach and avoidance exceeds the limited
capacity of the infants mind for organising coherent conscious experiences or
unitary memory structures (p. 55).
Dissociative attachment
The child develops a dissociative attachment style called disorganised/disoriented
or D-attachment (Liotti 1992, 2009; Main and Hesse 1990; McFadden 2011; Steele,
Van der Hart and Nijenhuis 2001; Van der Hart, Nijenhuis and Steele 2006).
D-attachment is strongly related to ongoing and chronic dissociation (Barach 1991;
Blisard 2003; Chu 2011; Howell 2011; Liotti 1992, 2009; Lyons-Ruth et al. 2006;
Ogawa et al.1997; Steele, Van der Hart and Nijenhuis 2001; Van der Hart, Nijenhuis

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and Steele 2006). D-attachment involves dissociation of the personality, which is a

shorthand term for our usual and enduring ways of being. Dissociation occurs
between ways of being that involve engagement in daily life and attachment
strategies and ways of being in which the individual is rigidly fixed in defences
(attachment cry, freeze, flight, fight, and collapse). In the face of perceived threat,
the individual may switch in an uncoordinated way between these very different
ways of being, resulting in what appear to be disorganised or contradictory actions.
In fact, these behaviours indicate an underlying dissociation of his or her personality.
A well-integrated person experiences all ways of being as belonging to him or
herself: I am me, in the past and the present, and in all ways of my being. But a
dissociative persons ways of being are not coordinated, they become activated at
the wrong time or in the wrong situations and are even actively in conflict with
each other. For example, a person might have a terrified, frozen child sense of self
in which he or she is mute and unable to move or think; an angry adolescent sense
of self in which he or she is perpetually enraged and avoidant of relationships, and
hates the child part; and an adult sense of self in which he or she is primarily
interested in work and avoidant of the child and adolescent parts (Van der Hart,
Nijenhuis and Steele 2006).
Dissociative parts of the personality
These compartmentalised functions (sense of self and related feelings, thoughts,
perceptions, predictions, and behaviours) are referred to as dissociative parts of
the personality (Van der Hart, Nijenhuis and Steele 2006). They are also called
self-states, alters, identities and other terms in the literature. By using the term
parts of the personality we do not mean that a person has more than one
personality, a common misconception of dissociative disorders. Rather, the
individual has more than one sense of self within a single personality, each of
which is related to particular action systems and generally in rather limited ways
of being. Each part has its own unique first-person perspective (that is, a sense of
me, myself, and I) that is different from another part (Nijenhuis and Van der
Hart 2011). These parts are fixed in relatively rigid patterns of thinking, feeling,
perceiving and acting. They are not very open to change and learning.
Next, we discuss two basic organisations of dissociative parts, one type
organised by the action systems of daily life, including social engagement, and the
other organised by the various defences. These distinctions have important
treatment implications that will be discussed throughout the chapter.
Apparently Normal part of the Personality (ANP)
Dissociative parts mediated by action systems of daily life (attachment,
exploration, care taking, sexuality, etc.) have been called apparently normal
parts of the personality (ANP), based on the dissociative individuals need to
function normally in daily life to the degree possible, in spite of significant

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symptoms (Van der Hart, Nijenhuis and Steele 2006). ANP involves the ways of
being in which the individual deals with daily life in the present as an adult.
Typically the patient as ANP is highly avoidant of any reminders of trauma. In
many cases, a single ANP is the major shareholder of the personality and is the
part of the patient that acts in the world and presents to therapy. In more severe
cases, there may be more than one ANP, for example one that goes to work, one
that takes care of the children, one that socialises.
In terms of attachment, the patient in ANP mode may have a wide range of
capacities and functions. Often he or she is quite avoidant and depressed as ANP,
but more functional individuals may be able to engage in at least some relatively
healthy relationships. Treatment is geared toward improving function in daily life
and helping the patient as ANP accept and respond empathically to other
dissociative parts.
Emotional part of the Personality (EP)
Other dissociative parts are fixated in traumatic memories, in which the individual
is often relatively unaware of the present, or at least responds to the present as
though it were the past. We call this living in trauma time (Van der Hart, Nijenhuis
and Solomon 2010). These parts are typically organised by defences (attachment
cry, flight, fight, freeze or collapse) and have been called emotional parts of the
personality (EP) because of their chronic and intense hyper- or hypoarousal (Van
der Hart, Nijenhuis and Steele 2006). Because EPs are fixed in defence, threat is
perceived where it does not exist, particularly in relationships. The attention of
these parts is narrowed to attend only to threat cues and so they often miss cues
that might indicate the present is safe. For example, an EP can become afraid
when the therapist frowns in effortful listening, misperceiving the frown as an
indication of anger. The patient as EP is unable to step back and observe the
situation as a whole, putting the frown into the proper context, or at least checking
out what it means with the therapist. He or she only reacts with fear.
The therapist helps ANP and EP aspects of the patient become less avoidant and
more accepting of each other, eventually leading to more adaptive and integrative
functioning for the person as a whole. The individual must learn to accept each
part as an aspect of his or her self, though this can take time for those who are
extremely avoidant.

Trauma-related phobias: why dissociation

becomes chronic
Dissociation is maintained over time first and foremost because the individual
whose development has been disrupted may not have the integrative capacity to
fully accept and realise what is dissociated. This is why skills building is an
essential part of the first phase of treatment, so that the capacity to function and
integrate is strengthened as much as possible. Secondly, because integrative

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capacity has been lacking for so long, the individual has developed major
avoidance strategies to prevent confrontation with what has been dissociated. This
leads to a series of inner-directed phobias.
Trauma-related phobias typically involve severe conflicts and fear, shame, or
disgust of the dissociative individuals experience and of various dissociative
parts. These phobias may be triggered strongly in relational contexts. They include:

the phobia of mental actions, that is, of inner experience;

the phobia of dissociative parts;
the phobia of traumatic memory;
the phobia of attachment and attachment loss;
the phobia of healthy risk taking and change;
and the phobia of intimacy.

Each dissociative part is typically isolated from other parts by these phobias that
involve painful conflicts, defensive strategies and resistances to therapy. For
example, an angry part might feel disgusted by a needy part and punish the patient
when needs are expressed, while the needy part feels overwhelmed, criticised and
afraid of the angry part.
Overcoming inner-directed phobias is a central task in fostering integration of
the individual as a whole. Phobias are addressed in large part in sequence within
the three phases of treatment, beginning with the broad phobia of inner experience
(thoughts, emotions, sensations, wishes, perceptions, predictions, etc.) and the
patients experience with safety and threat in initial contacts with the therapist
(Steele, Van der Hart and Nijenhuis 2001, 2005; Van der Hart, Nijenhuis and
Steele 2006).

Phase-oriented treatment of complex developmental

trauma disorders
Phase-oriented treatment involves three overlapping phases of treatment. The
initial phase focuses on safety, skills building, stabilisation, symptom reduction
and building a co-operative therapeutic alliance in the face of multiple and
contradictory transferences. Once a modicum of safety has been established and
sufficient skills are in place, the second phase commences, in which traumatic
memories and enactments are addressed more thoroughly. In this phase important
work on insecure attachment to perpetrators is also accomplished. This phase is
followed by a third phase of grieving, solidifying and furthering integrative gains,
becoming more accepting of life as ever-changing, and promoting healthy risktaking to develop more intimate and meaningful relationships. A return to earlier
phases is often necessary over the course of treatment, according to the needs of
the patient. The foundation for therapy with severely traumatised individuals is a
secure therapeutic relationship that has strong boundaries.

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Phase 1: establishing safety, stabilisation and

skills building
In this first phase of treatment, patients must first learn stabilisation skills,
including how to establish and maintain safety, arousal and impulse regulation,
the ability to reflect on experience (Fonagy 1997), energy management, relational
skills, executive functioning, and skills to overcome chronic dissociation, as well
as other daily life skills (Boon, Steele and Van der Hart 2011; Chu 2011; Cloitre,
Cohen and Koenen 2006; Courtois and Ford 2009; ISSTD 2011; Steele, Van der
Hart and Nijenhuis 2005; Van der Hart, Nijenhuis and Steele 2006). The therapist
should take an initial stance of interest and modulated empathy with the patient as
ANP, neither overly warm nor distant in feeling tone and not too probing (Steele,
Van der Hart and Nijenhuis 2001; Van der Hart, Nijenhuis and Steele 2006).
Establishing safety
Much emphasis has been placed on the primacy of the therapeutic relationship.
However, what is often missed is the need for the patient to first experience a
physical sense of safety that allows for curiosity and co-operation, prior to
attachment with the therapist. Dissociative parts (EPs) that are fixed in fight,
flight, freeze, or collapse defences are focused on cues of threat, not relationship.
Early in therapy, therefore, relational interventions should generally be preceded
by those that address safety and collaborative co-operation, following the principle
that attachment cannot occur as long as serious threat is perceived. This involves
more than just cognitive awareness of safety, because patients often lament, I
know I am safe, but I dont feel safe! The therapist helps the patient identify the
physical sensations and postures that accompany being safe in order to have an
experiential knowing or felt sense of safety (Ogden, Minton and Pain 2006),
sometimes alternating awareness back and forth between a sensation associated
with danger and one associated with safety. It is only then that work can proceed
on earning secure attachment, with its felt sense of (relational) security.
Working in a window of tolerance
Treatment should be conducted in such a way that it remains within the patients
overall window of affective and integrative tolerance (Boon, Steele and Van der
Hart 2011; Ogden, Minton and Pain 2006; Van der Hart, Nijenhuis and Steele
2006). The best overall indication of whether therapy is being well paced is how
well the patient is functioning in daily life. In general, if functioning over time is
status quo or improving, therapy is likely going well. Learning, co-operation and
secure attachment cannot exist outside the range of what the patient can tolerate.
All parts of the patient, beginning with the patient as ANP, need to learn to
recognise early signals of distress and practise distress tolerance and other
regulatory skills (Boon, Steele and Van der Hart 2011). The therapist should track

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small changes in the patient from moment to moment so that dysregulation can be
addressed immediately it begins to occur (Ogden, Minton and Pain 2006). For
example, the therapist can notice that the patients speech has become shaky, her
mouth is dry, she is shifting in her seat and looking around the room. Instead of
continuing to talk, the therapist can ask the patient what she is experiencing and
together they can work toward regulation. The therapist is thus using his or her
own capacities for regulation and reflection to help the patient learn self-regulatory
skills. This is an essential component of secure attachment that builds safety and
co-operation and lays the groundwork for integration.
Orienting parts to the present
Dissociative parts, in particular EPs, are often disoriented to time, place and even
person, living in trauma time in which they perceive danger. This makes it
extremely difficult for the individual to have safe relationships, including with the
therapist. To this end, all parts are encouraged to focus on present experience in
the room with the therapist. Parts are first oriented to place, and then to person, as
efforts to develop attachment might be too activating at first. For example, Let all
parts of you look around the room and see where you are. Can you notice
something that can be a reminder to your whole mind of the safe present? Parts
more oriented to the present are encouraged to inwardly remind other parts of the
present. Focusing on current reality for all parts of the patient is an important
integrative action that supports more accurate perceptions of the present and more
capacity to respond appropriately.
Overcoming the phobia of inner experience
The patient must become increasingly aware of, tolerate and understand inner
experiences that consist of mental actions. All interventions incorporate implicit
and explicit approaches that support overcoming this phobia. The patient, first as
ANP, must learn to accept feelings, thoughts, sensations, wishes, needs, fantasies
and perceptions without assigning value judgements to them. The patient is
routinely encouraged to be aware of and explore his or her present experience
(Ogden, Minton and Pain 2006). The therapist should be consistently curious with
the patient about inner experience in the moment. For example, the therapist
might ask, As we are talking about your job, what do you experience right now?
Can you notice if parts of you have some thoughts or feelings about it? In this
way the therapist constantly attends to process that accompanies content, and is
able to slow down and address the patients immediate experience.
Overcoming the phobia of attachment and attachment loss
The phobia of attachment in some parts of the personality is paradoxically
accompanied by an equally intense phobia of attachment loss (rejection,

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abandonment, criticism) in other parts. The therapist should recognise that both
attachment and attachment loss are feared, and therefore must find a delicate
balance between enmeshment and distancing emotions and behaviours (counter
transferences), both of which may be extremely intense for the therapist (Dalenberg
2000; Steele, Van der Hart and Nijenhuis 2001).
Coping with counter transference
One of the most essential interventions in working with the attachment phobia is
for the therapist to understand and work with his or her counter transference
reactions, rather than act on them. The therapist is pulled toward extreme emotions
with these patients like no others. These may include rage, hatred, shame, guilt,
disgust, fear, despair, hopelessness, helplessness, intense love and loneliness
(Dalenberg 2000; Davies and Frawley 1994; Steele, Van der Hart and Nijenhuis
2001). The therapist can also be seduced by feelings of omnipotence and
overwhelming care taking (I can save this person), engendered by the patients
own wishes and the unresolved past of the therapist. Supervision and consultation
for these difficult emotions are strongly recommended, even for experienced
therapists (Chu 2011; Courtois and Ford 2009; Dalenberg 2000; Steele, Van der
Hart and Nijenhuis 2001; Van der Hart, Nijenhuis and Steele 2006).
Working with the conflict between attachment and
attachment loss
The patients combination of attachment minimising and maximising strategies
should be recognised by the therapist (Steele, Van der Hart and Nijenhuis 2001;
Van der Hart, Nijenhuis and Steele 2006). The more need is evoked for the patient
in the relationship with the therapist, the more defensive parts (EPs) become
fearful and enraged, fearing the therapists withdrawal or rejection. They are
ashamed of dependency and greatly fear vulnerability. They turn shame and anger
inward toward needy parts, resulting in dysregulation and often in self-destructive
behaviours (drinking, self harm, etc.). These situations, in turn, create more crises,
perpetuating a maladaptive needshamerage cycle (Boon, Steele and Van der
Hart 2011). The most important interventions are for the therapist (1) to
consistently encourage adult aspects of the patient (ANPs) to acknowledge
dependency needs and accept responsibility for child parts in collaboration with
the therapist; and (2) to help the patient resolve the conflict between these young
needy parts and defensive parts that avoid attachment.
The phobia of attachment loss is often mediated by the attachment cry, the early
defence of calling out for a caregiver. Many young child-like EPs are fixed in this
defence. Behavioural manifestations typically include difficulty ending and
leaving sessions, crisis calls in between sessions, panic when the therapist goes
away, frantic expression of need and other attempts at frequent contact with the
therapist outside of sessions. These behaviours are unfortunately often labelled as

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manipulative, but actually represent efforts to attain safety via care taking and
attachment, since these parts are dissociated from adult inner resources that could
be soothing and helpful.
Treatment does not call for the therapist to meet every need and demand and be
constantly available, but rather to be consistent and predictable (Steele, Van der
Hart and Nijenhuis 2001). In fact, the therapist needs to set appropriate boundaries
and limits on contact outside of session. This helps prevent too many dependency
behaviours that can upset the equilibrium of the patient, and allows him or her to
bring dependency needs into the therapy room where they can be talked about.
The following case example illustrates some ways of working with this conflict.
Marge is a 48-year-old woman with a dissociative disorder who was extremely
phobic of a child part that cried all the time, calling out for help, and also of an
inner critical part that was always telling the child part to shut up internally.
This inner conflict was so intense that the patient began calling the therapist
frequently between sessions to get help with her anxiety. The therapist first
helped the patient verbalise more about her conflict about dependency on the
therapist and addressed her concerns. Then she asked for permission to
address the critical part and determined that the function of this part was to
maintain safety by keeping the crybaby quiet so that the child part would not
cry too much and get in trouble. This critical part was living in trauma-time,
unaware of the present, and was well-defended by rage against dependency
needs. The therapist helped orient the critical part to the present and agreed
that she also did not want the child part (or any part of Marge) to be in such a
painful state. The therapist then encouraged Marge to understand the function
of the critical part, as well as the dependency yearnings of the child part. She
gradually became less phobic and more compassionate of these parts of herself
and could accept their functions. The therapist supported an alliance between
the critical part and the adult self of the patient, which in turn were able to
support the child part in being acknowledged and helped in appropriate ways.
This significantly calmed the inner conflict.

Overcoming the phobia of dissociative parts

By definition, at least some dissociative parts are avoided because the patient
experiences them as feared, shameful or disgusting. As noted above, dissociative
individuals tend to wish either that the therapist would get rid of parts, or work
with them without the involvement of the patient as ANP. Beginning early in
therapy, the therapist should encourage active inner communication and cooperation between the patient as ANP and other parts in a paced manner that
fosters integration over the long term. The therapist might say something like, I

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can empathise with your wish for those needy and angry parts of you to disappear.
Yet, in all these years, you have not been able to make that happen. That is because
these aspects of you are a normal part of being human. I am confident that together,
you and I can begin to make sense out of all these ways of being, and help you deal
with them so that you feel more safe and comfortable with every part of yourself.
Treatment is directed first towards helping the patient as ANP understand and
become more empathic and engaged with all parts of him or herself, orienting
parts to the present, establishing safety and inviting all parts to become involved
in a co-operative therapeutic alliance. The therapist may often say something like,
It is important that you and I invite all parts of you [or every part of your mind,
or you in all your ways of being] to listen and give feedback about what we are
discussing now. When the therapist works with parts living in trauma time (EPs)
in the first phase of treatment, it should be to establish safety, orient to the present
and develop co-operation in therapy and in daily life with other parts, rather than
exploring traumatic material.
Once the patient is stable, functioning in daily life to the degree possible, can
engage in regulation, and has some inner awareness and co-operation, the
treatment of traumatic memories can take a more prominent place in therapy.

Phase 2: integrating traumatic memories

The major phobia addressed in Phase 2 is that of traumatic memories, many of
which involve severe attachment disruptions or trauma. In addition, disorganised
attachment to abusive and neglectful family members must also be addressed. In
this chapter, we focus on the attachment aspects of Phase 2. Further reading on the
treatment of traumatic memories can be found in Chu 2011; Kluft 1996; Van der
Hart, Nijenhuis and Steele 2006; and Van der Hart et al. 1993.
Treatment of insecure attachment to the perpetrator
The inner conflict between attachment to and defence against caregivers who are
perpetrators becomes heightened when traumatic memories are reactivated. Some
patients may be enmeshed with their families in the present, unable to set healthy
boundaries and limits. Simultaneously, certain dissociative parts of the individual
may hold strong feelings of hatred, anger, shame, neediness, or terror toward
family perpetrators and others (Steele, Van der Hart and Nijenhuis 2001).
The therapist must empathically explore all the patients conflicted feelings and
beliefs related to perpetrators and not blame them, remembering that one part of
the patient can have an un-ambivalently positive view of the perpetrator, while
another holds a completely negative view. For example, the therapist can say, I
can empathise that parts of you hate your mother she hurt you so very much. On
the other hand, I can also empathise with feelings of love and yearning that some
parts of you experience she was sometimes kind. I wonder if perhaps all parts of
you might join in understanding and accepting how these very different feelings
can co-exist. Lets explore how you manage this painful conflict.

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Working with perpetrator-imitating parts

One particular type of part that bears mentioning is those that imitate the
perpetrator. They have so strongly identified with the perpetrator that they literally
experience themselves as being that person as he or she was in the past.
Interventions with these parts should begin early in therapy and are intensified in
the second phase of treatment (Blisard 2003; Boon, Steele and Van der Hart 2011;
Chu 2011; Howell 2011; Steele, Van der Hart and Nijenhuis 2001; Van der Hart,
Nijenhuis and Steele 2006). Treatment is directed toward time orientation to the
present, challenging the fixed belief that the part is the original perpetrator and
providing psychoeducation about the original survival value of these parts so that
empathy can be developed. The therapist should first focus on safety and cooperation rather than attachment with these parts.
Overcoming phobia of traumatic memory
This is one of the most difficult phobias to overcome, requiring high and sustained
integrative capacity. The intensity and duration of exposure, or guided synthesis,
must be matched to the patients overall capacity to integrate these painful
experiences (Van der Hart, Nijenhuis and Steele 2006). As memories of attachment
trauma surface, traumatic transference will heighten. The therapist should be
acutely aware of multiple and contradictory transference and counter transference
enactments.
It is essential that the therapist help the patient remember rather than relive
traumatic experiences. This is accomplished by careful pacing that ensures the
patient is grounded in the present, within his or her window of tolerance, and in
contact with the therapist during these sessions (Van der Hart, Nijenhuis and
Steele 2006).

Phase 3: Personality integration and rehabilitation

Phase 3 involves higher levels of integration, such that dissociative parts are
accepted and integrated as aspects of a single self and personality. It is also a time
for the patient to focus increased energy on creating a more fulfilling and adaptive
life. During this period of therapy, the phobia of attachment and attachment loss
returns in the form of developing new and healthy relationships and risking
intimacy.
Though begun early in Phase 1, ongoing resolution of the phobia of healthy risk
taking and change becomes a more targeted focus of Phase 3. As the patient makes
efforts to be more involved in present life over the course of this phase, he or she
increasingly experiences the conflict between the desire to change and intense
fears of doing so. In fact, adaptive change in this phase of treatment requires some
of the most difficult integrative work of painful grieving and risk taking.

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The patient should be assisted in approaching the phobia of intimacy in a

graduated manner; overcoming fear of emotional intimacy prior to physical and
sexual intimacy (as opposed to just having sex), as the last two require the first to
be in place. Usually there is extreme resistance to the experience of loss, an
inevitable risk associated with intimacy. Many individuals say, I would rather not
have any relationship than run the risk of getting hurt so badly again. The patient
must slowly learn to tolerate the very ordinary conflicts and difficulties that arise
within normal intimate relationships. This requires adequate conflict resolution
skills, empathy, regulation and reflective functioning skills, and the ability to
distinguish between minor and major relationship problems (Boon, Steele and
Van der Hart 2011; Courtois and Ford 2009; Steele, Van der Hart and Nijenhuis
2001; Van der Hart, Nijenhuis and Steele 2006). A case example follows.
Greg met a nice woman in an evening class he was taking. He had immediate
fears that she would not like him, which his therapist challenged and helped
him overcome. Then a part of him began having fantasies of getting married to
her, without even going on a date. Gregs therapist slowed him down and
helped him realise he was retreating into a fantasy to avoid the hard work and
risk of building a relationship. The therapist helped him take one small step at
a time: making small talk, showing interest in what the woman was talking
about, learning about the timing of sharing more vulnerable things. Greg asked
the woman to go out for coffee but she was not able to go during the time he
asked. He was devastated, and a part of him got angry in defence and wanted
nothing to do with her. But gradually he was able to accept the possibility that
it was not a rejection. The therapist continued to help Greg work with his fear
of getting close and his fear of loss. After a few weeks, he asked again, and the
woman accepted his offer.

Finally, it is common for additional traumatic memories and dissociative parts to

emerge in Phase 3 in response to a growing capacity to integrate. During such
times, Phase 1 and Phase 2 issues need to be revisited. Patients who cannot
successfully complete Phase 3 and reach the point where they no longer have
dissociation of the personality often continue to have difficulty with normal life,
despite significant relief from traumatic intrusions (Kluft 1993).
Integration
All interventions across the course of therapy should promote a higher capacity
for integration in the patient. The more the therapist is even-handedly inclusive of
all parts in therapy, accepts them as inter-related aspects of one individual rather
than separate personalities and encourages the patient as a whole to accept these

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parts of him or herself, the more consistently integration is likely to occur.

Additional techniques to promote integration among dissociative parts are beyond
the scope of this chapter, and may be found in Boon et al. 2011; Chu 2011; Van
der Hart et al. 2006; and Kluft 1993, 2006.

Conclusion
Attachment disruptions and attachment trauma are inherent in chronic childhood
traumatisation and affect not only the relationships of adult survivors in daily life
but also the therapeutic relationship. Early attachment trauma may manifest in
therapy in the patients phobias of attachment and of attachment loss vis--vis the
therapist, often simultaneously present among different dissociative parts of the
personality and known as D-attachment. Phase-oriented treatment, as the standard
of care, pertains to all dimensions of therapy, but also, and especially, to helping
patients to overcome their attachment-related phobias.
The focus on overcoming attachment-related phobias evolves over the course
of these phases, with initial establishment of a felt sense of safety prior to
attachment. In Phase 1 work with attachment phobias of ANPs are emphasised,
while in Phase 2 conflicts among parts (EPs and ANPs) regarding attachment to
the perpetrator is addressed. In Phase 3, the patient as a whole person strives
toward greater intimacy (and adaptive risk taking) in relationships.

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